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Episode 4  |  38:47 min

S1E4 | Immunotherapy: Harnessing the power of the immune system

Episode 4  |  38:47 min  |  08.11.2020

S1E4 | Immunotherapy: Harnessing the power of the immune system

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This is a podcast episode titled, S1E4 | Immunotherapy: Harnessing the power of the immune system. The summary for this episode is: The body’s immune system is a powerful force, protecting us against infection, illness and disease. But sometimes, those protections break down, allowing cancer to form and grow. In one of the most exciting areas of cancer treatment, doctors are discovering more and more about how to harness the immune system’s power to recognize and fight cancer. In this episode of Focus on Cancer, Pat Basu, MD, MBA, President & CEO of Cancer Treatment Centers of America® (CTCA), and his guest, Ankur Parikh, DO, Director of the Precision Medical Program at CTCA, discuss the past, present and promising future of immunotherapy.
The body’s immune system is a powerful force, protecting us against infection, illness and disease. But sometimes, those protections break down, allowing cancer to form and grow. In one of the most exciting areas of cancer treatment, doctors are discovering more and more about how to harness the immune system’s power to recognize and fight cancer. In this episode of Focus on Cancer, Pat Basu, MD, MBA, President & CEO of Cancer Treatment Centers of America® (CTCA), and his guest, Ankur Parikh, DO, Director of the Precision Medical Program at CTCA, discuss the past, present and promising future of immunotherapy.
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Ankur Parikh, DO
CTCA Precision Medicine Program Director
“I believe an integrated treatment approach is what is best for patients, and Cancer Treatment Centers of America® (CTCA) really embodies that,” says Dr. Ankur Parikh, Medical Director of Precision Medicine at CTCA® and Hematologist & Medical Oncologist. “I decided to join CTCA because I was very impressed with the patient care model. I wanted to be part of a team that manages all aspects of what patients need to fight cancer.” The hematologist and medical oncologist became a member of our team of cancer experts at our Philadelphia hospital in 2012, and has a strong interest in the treatment of gastrointestinal cancers. He notes, “I really enjoy the work environment at CTCA. The team is extremely helpful and accommodating. It’s also great to work in a place where you know your patients are being taken very good care of. Communication among the staff and the team approach to patient care are strengths of CTCA.” Dr. Parikh strives to personalize treatment for each of his patients and educate them so they are a part of the treatment planning and decision-making process. He adds, “I think it’s important to maintain open communication so that we’re on the same page and the patient’s best interests are looked out for.” Board certified in medical oncology, hematology and internal medicine, Dr. Parikh earned an osteopathic medical degree from Kirksville College of Osteopathic Medicine in Kirksville, Missouri. He completed an internal medicine residency at Riverside Methodist Hospital in Columbus, Ohio, followed by a hematology-oncology fellowship at the National Heart, Lung, and Blood Institute of the National Institutes of Health in Bethesda, Maryland. Prior to pursuing a medical degree, Dr. Parikh completed a pre-med bachelor’s degree at Truman State University in Kirksville, Missouri. Dr. Parikh has served as a principal and associate investigator for clinical research protocols involving myelodysplastic syndrome and aplastic anemia. He has also written book chapters on hematology topics and his work has been published in various peer-reviewed journals. Dr. Parikh is a member of the American Society of Hematology, American Society of Clinical Oncology, American Society for Blood and Marrow Transplantation and the American College of Physicians.
Learn more about Dr. Parikh

Dr. Pat Basu: Hi. I'm Dr. Pat Basu, the host of Focus on Cancer, the show that answers everyday questions that cancer patients have about their treatment and the delivery of their care. On today's show, I'm very excited to welcome Dr. Ankur Parikh. Dr. Parikh is the Medical Director of Precision Medicine at Cancer Treatment Centers of America and a world- renowned expert in precision medicine and immunotherapy. Dr. Parikh, welcome to the show.

Dr. Ankur Parikh: Thanks, Pat. Nice to be here. Thanks for having me.

Dr. Pat Basu: Well, we're grateful that you're taking the time away from treating patients and fighting cancer to share your expertise and thoughts on the exciting world of immunotherapy. So for our audience today, I'm really hoping to open up the canvas and the mystery on everything about immunotherapy, really giving our audience a sense of what it is and not only the advances that we've made today, but what I would say are some incredible advances to come. So looking forward to doing that with you, Dr. Parikh. I know you and I share an incredible passion and excitement about the directions in which immunotherapy can take us. But before we get directly into those topics, I love to just ask our guests a little bit about what brought them to this battle in cancer. So in your professional career, what caused you to become a hematologist- oncologist?

Dr. Ankur Parikh: Yeah, sure. Great question. I was an oddball. I knew in high school that not only did I want to be a doctor, but I wanted to be an oncologist. Throughout my high school years, I was able to see firsthand the impact that cancer had not only on people, but also their loved ones and family and friends surrounding them. One example is my uncle was diagnosed with colon cancer back when I was in high school. Thankfully, he's doing great now, but I got to see firsthand the impact that going to treatments and dealing with chemotherapy and, more importantly, the stress that had caused the family as well, and so I kind of kept this curiosity as I got into medical school and did more rotations in oncology and got to really see all the things that were out there, such as stem cell transplants to treating solid tumors. It really just continued to fuel that fire of really understanding what is out there in oncology, and what was really mesmerizing was the pace at which new therapies were coming along, whether it be targeted therapies, immunotherapies, and really perfecting a lot of this. So as I got more advanced in my training, the landscape just kept evolving, and it was just that excitement that kept me motivated to keep going in this field.

Dr. Pat Basu: Well, thank you for sharing that. I personally always say that I feel very privileged to do what we do. The humanity and the care of cancer patients is always so fulfilling. The science, as you said, is always advancing and so dynamic. So I'm sorry that you had to be exposed to this battle at an early age with your uncle's diagnosis, but I'm glad to hear that he's doing better, and I'm certainly very grateful that you chose to become an oncologist and certainly the Director of Precision Medicine at Cancer Treatment Centers of America. So tell me a bit about your role. What do you do? What do you focus on as the Director of Precision Medicine?

Dr. Ankur Parikh: Sure. So I've been in this role for quite a few years now, and it's really interesting, because we didn't really learn much about genomics in medical school. We know that there's targeted therapies out there, and certain targeted therapies work better for specific cancers, but really, in the past few years, it's been extremely groundbreaking with the role of genomic testing and sort of where that fits in the paradigm of treating advanced cancers. I do a lot of genomic testing. We have a great program here at Cancer Treatment Centers of America, looking at these options for our patients and enrolling them on clinical trials. So for the past few years, I've really spearheaded that organization to be able to offer these types of therapies for our patients and diagnostic testing and then trying to bring clinical trials here to offer these treatments that we think may potentially work better than conventional standard chemotherapy, which doesn't really necessarily target a specific mutation that we think might be driving the cancer.

Dr. Pat Basu: Terrific. Well, on a previous show, we had Dr. Bonilla on, talking about clinical trials and the power of that. Certainly in a moment, we're going to really dive deep into immunotherapy with you, but you mentioned genomic testing. For our audience, can you just kind of break that down? What exactly is genomic testing? Why is it important? Why is it done?

Dr. Ankur Parikh: Yeah, sure. So it gets confusing, because I think there's genomics and there's genetics. So one thing to always keep in mind is genetics is what you were born with, right? So do you have a hereditary cancer syndrome? Genomics is really looking at the actual cancer itself, so not necessarily something you were born with, but it could be something that you acquired. So usually what we do is either a biopsy of the tumor or you can also do a blood test, looking at circulating tumor cells, and then you do next generation sequencing or genomic testing on those cells itself to help identify what mutations are in the tumor, and are there any mutations that might be what's called driver mutations that's driving the process of that cancer growth and spread? If there is, there could be a treatment out there that potentially blocks that mutation.

Dr. Pat Basu: Yeah, no, that's a great description. So genetic testing is really some of the things that in oncology can predispose you potentially to having cancer, whereas genomic testing is much more specifically about the criteria of the tumor itself, the mutations, and that gives us some insight into treating it.

Dr. Ankur Parikh: Right.

Dr. Pat Basu: I think that's a great segue into the topic that we're going to dive deep in today with you, Dr. Parikh, and that is immunotherapy. I'm very excited to talkabout those advances, but let's just start grounding our audience. A lot of people have heard the term immunotherapy, but a couple of big words put together. What exactly is immunotherapy?

Dr. Ankur Parikh: Yeah, there's a lot of buzz around immunotherapy. It's such a hot topic. Most of my patients will always ask me at this point," Am I a candidate? Can I get immunotherapy?" So I think it's important to understand sort of where we're at today. I mean, I think if we can offer immunotherapy to our patients, we certainly do, just because we see a lot of great outcomes, less toxicities than conventional chemotherapy, but basically the premise is that a lot of times with cancer, your own immune system is shut down. So for some reason that we're still learning, cancer could potentially cause the immune system to think that really nothing is going on. So if you have an infection, for example, your body recognizes as a foreign entity, the immune system goes and attacks it. That's not always the case with cancer, for multiple reasons. So what immunotherapy basically does is it wakes up your immune system. It takes that pedal off the brakes to activate those T cells, which can go and fight the cancer.

Dr. Pat Basu: That's very helpful. With my patients, I sometimes make the analogy that your immune system is your body's national security force or national defense, and it is so trained to keeping out foreign invaders, primarily infections, but there is a secondary purpose, which, again, sticking with that metaphor is to stop let's call it kind of homeland security or homegrown terrorist attacks, which can be trickier to detect. So I sort of use that metaphor. Would it be safe to say that, to continue that analogy, immunotherapy sort of helps our FBI or our domestic forces more readily identify a threat in the sense of a tumor?

Dr. Ankur Parikh: Absolutely, Pat. That's a great example. So immunotherapy is basically waking up that immune system, telling them," Hey, something's going on. Go. Go fight it." So that's a great metaphor for really what's happening.

Dr. Pat Basu: Perfect. So with that as a background, let's talk about the various immunotherapy drugs. How do these drugs work, Dr. Parikh?

Dr. Ankur Parikh: Yeah, so they basically work on different ways of stimulating the immune system. So the more common ones that we prescribe are checkpoint inhibitors. You see lots of commercials, lots of clinical trials using that. So as we talked about earlier, basically what happens is when you have a tumor cell and it can attach to an immune cell or a T cell, it'll deactivate it. It basically then knocks out the immune system. So what these checkpoint inhibitor drugs do is they block that signal. It gives the inability for that tumor cell to bind with that T cell. So therefore, it activates that T cell so it can go now and fight that cancer cell.

Dr. Pat Basu: Perfect. So kind of sticking with that metaphor, it almost sounds like these tumors try and kind of hypnotize or disguise themselves from being detected, and what this drug will do is sort of alert the FBI, if you will, that now there is this internal homeland threat, and your body needs to get on very quickly to stopping it.

Dr. Ankur Parikh: Yeah, exactly. So that's just one way it can work. There's other treatments, like cytokines, where if someone doesn't have a competent or a healthy immune system, you basically give them what they need. There's cancer vaccines. So there's lots of different ways we're trying to manipulate the immune system to fight this disease.

Dr. Pat Basu: Terrific. One of the questions I sometimes get from patients, Dr. Parikh, is," Okay, is my entire immune system getting revved up? Is my entire immune system activating? Will I be less susceptible to infections and the like?" I always tell them that's not how it works and that's not the case, but can you kind of shed a little bit more light on that?

Dr. Ankur Parikh: Yeah, no, that's a great question. I have patients that say," Oh, so if I get immunotherapy, I'm basically Superman now, right? I can do what I want." We're like," No, no, wait a minute. I don't think that's the case." So no. I mean, there's no evidence right now that by activating or stimulating your immune system, you are now technically immune or not prone to getting other infections. So it's still recommended that to get the vaccines that you need, you take the proper precautions, if you're sick, you get the antibiotics. So no, there's really no correlation right now.

Dr. Pat Basu: So Dr. Parikh, you mentioned that the way that immunotherapy works does not necessarily just overall rev up your immune system and turn you into Superman. Any kind of insights... I know there's not really a whole lot of evidence yet, but any impact on what immunotherapy would do with respect to COVID-19?

Dr. Ankur Parikh: Yeah, no, great question. I think that's a relevant topic right now, and the answer is we just don't know, because the way immunotherapy works is so different than a vaccine, per se, to help fight infections that you may develop in the future that I don't think we can make that same leap or bridge to say that one's going to positively affect the other. So for my patients that are on immunotherapy, I still tell them," You've got to use the same guidelines that the CDC, WHO recommending with appropriate face masks and hand washing and social distancing and all of that," because there's no evidence currently that being on immunotherapy will protect you from COVID- 19.

Dr. Pat Basu: Yeah. Maybe sticking on that topic, the word immunotherapy can encompass a lot of things. It may be a little confusing. I loved your background earlier on it. Yes, it's activating the immune system. It's related to the immune system, but it's different in fundamental ways than people traditionally think about it. So I know some people have asked, you use the immunotherapy vaccine. Earlier, you mentioned that. That's very different than, for instance, the vaccine that's being developed for COVID- 19. Do you want to just kind of lend some separation between kind of the difference here to avoid any confusion?

Dr. Ankur Parikh: Right, right. Yeah, so it's not, unfortunately, a one size fits all here. I think the COVID-19 vaccine that's under development is very specific to the COVID- 19 virus. So with that said, all these other immunotherapy cancer treatments that we're talking about is independent of sort of what's going on, and so we're still looking to get the answers as the Phase 3 trials accrue and we start identifying which vaccines will protect you from COVID- 19. So hopefully we get those answers by the end of this year or early next year so that we can start applying that. But I think for today, there is no link currently of cancer immunotherapy drugs potentially protecting you from COVID- 19.

Dr. Pat Basu: Thank you for clarifying that, and thank you for laying this background on what immunotherapy is, how these drugs work. So tell us, well, why is immunotherapy such a promising area of cancer treatment?

Dr. Ankur Parikh: Yeah, just because it's a novel way to treat cancer. For decades now, we've been using chemotherapy, radiation, surgery, and, of course, that still has a place in cancer care. But with the trials that occurred that really demonstrated the benefit of immunotherapy, when it works, it can work extremely better than chemotherapy does with a lot less toxicities. So you're giving someone a better treatment that isn't going to make them as sick. You don't get the traditional side effects of hair loss, nausea, that numbness and tingling, that stuff that you traditionally think about with chemotherapy. So a lot of my patients that get immunotherapy really feel well. There are side effects, don't get me wrong, but a lot of times, they just feel so much better than they did when they were on chemotherapy, and a lot of times, outcomes are much better.

Dr. Pat Basu: Yeah, I agree with you. It's one of the things that I love and gets me so passionate about immunotherapy, is that idea that you can get better treatment efficacy and much less side effects, generally speaking, on the body because you're activating your own immune system, because you are really targeting the therapy. Frankly, I think that it's already so advanced, great therapy with less side effects, that we're actually going to see even more advancements in the future. So tell me about the direct impact that this is having on patients.

Dr. Ankur Parikh: Yeah. I mean, patients really want this treatment, and, now, it doesn't work for all cancers quite yet, right? So that's where the role of clinical trials and research still has a huge responsibility to help identify which patients are likely to respond to these treatments. So you can't just give it to everybody, because it doesn't always work. But really, this is the future of cancer care, immunotherapy, combination treatments with potentially chemotherapy or targeted therapies. There's lots of clinical trials now not only looking into advanced cancers with immunotherapy, but could we do it early on? So there's still lots of questions that need to be answered, and I really think in the next two to three years, we're going to get a lot more information.

Dr. Pat Basu: Yeah. I agree. Very, very excited about the progress that's being made. If you don't mind, I know there's many, many examples, but I think one of the things that I love about what we do is the humanity and really working directly with the individual patients, treating every single patient as we would treat our mother or father. Can you share with our audience maybe a specific patient example of a case where immunotherapy made a key difference?

Dr. Ankur Parikh: Yeah, absolutely. So, thankfully, I think most oncologists have great stories like this now. I think about years ago or about four years ago, rather, when sort of we were just exploring a lot of immunotherapy in specifically lung cancer patients. I had a patient with advanced lung cancer that traditionally got the chemotherapy that worked for a while, stop working, next round of chemo, to the point where now we exhausted most of our chemotherapy options, and she was really suffering from her symptoms, from the tumors in the lungs really compromising her breathing. So immunotherapy had just sort of come around and gotten approved at the time, and I offered it to her. Really within three months, she had a significant improvement in her symptoms. I didn't even need to get a CAT scan to tell that it was working. She was breathing so much better, going for walks with her husband, and, really, this continued. It got to a point where we got her scan results and things were getting better and better. Now there's really no evidence of disease. Again, I want to clarify this isn't typical for necessarily everybody, but for her, she had a great, great outcome, where about two years ago, we actually stopped her immunotherapy because we decided to just see what would happen. I just saw her a few months back, and her scans still look great. She has a great quality of life. So it's just really remarkable how well some people do with immunotherapy.

Dr. Pat Basu: It really is. I agree, and it's so fulfilling for certainly us as the doctors, getting to care for those patients. But I love meeting patients with that result and their family members. It's certainly the more of those stories, the better. That being said, I think you brought up some really good points. Major advancements, incredible way of treating with generally better treatment, where it's applicable, and less side effects. That being said, what are some general side effects that are common for people to be aware of?

Dr. Ankur Parikh: Yeah. So the easy way I try to tell my patients to think about it is think of symptoms of the flu, just magnified by a lot. So because you're activating your body's immune system, technically, your immune system can attack other organs in your body. So if it attacks the colon, for example, you may get diarrhea. If it attacks the liver, you may develop jaundice. You can get a skin rash. So, really, it can attack any organ, but the more common side effects are fatigue, rash, diarrhea. It can affect your thyroid. But most people will experience just minor symptoms, where you may have to just delay in the treatment or, for a short course, just give them some steroids to suppress their immune response, and the symptoms get better. On occasion, unfortunately, there are some people that just can't tolerate immunotherapy because their side effects are just too much, where you wouldn't necessarily rechallenge them again. But for the majority of patients, it's very well tolerated.

Dr. Pat Basu: Yeah, no, I think that's another aspect that I love about immunotherapy, is not only the decreased side effects, but the fact that in those who may have them, many of them can be addressed appropriately with steroid treatments and other therapies to bring those down. So, well, Dr. Parikh, you are frankly a world expert in precision medicine and immunotherapy and taking care of patients. But I know you're also very active in the advancement of research and trials and everything that's on the horizon for immunotherapy. So can you share with us, what do you see in the future of immunotherapy and its impact on cancer care?

Dr. Ankur Parikh: Yeah, Pat, great question, and so I'm just so excited to see sort of what the future is going to bring, because right now, we want to be able to offer immunotherapy or really effective therapies to our patients that don't have a lot of side effects, but you've got to figure out who's the right type of patient for that type of treatment? So sort of going back to the genomic piece, we do know that there are certain mutations that tumors may have that would suggest that immunotherapy is going to work for you. So one great example is something called tumor mutational burden, which is basically a combination of just neoantigens in cancers. Recently, the FDA approved immunotherapy for patients that have a certain tumor mutational burden expression in their cancer. So this is such a novel or just groundbreaking approval, because it doesn't matter what type of cancer you have. Doesn't matter if you have breast cancer or colon cancer or pancreatic cancer. As long as your tumor mutational burden hits the specific criteria, the likelihood of response to immunotherapy is much higher and can be offered. So I think, moving forward, we're going to really identify patient populations that will respond to immunotherapy because of specific tumor signatures they may have, but on the flip side, also identify patients that won't respond to it. So therefore, we're not putting them at risk at these treatments that still, for the most part, are safe, but there are people that do have really bad side effects from it. So you're going to avoid giving them that treatment.

Dr. Pat Basu: That's very helpful. You mentioned tumor mutational burden. I know that's one of those terms, again, that patients are starting to hear a little bit more of. Can you just do one sort of deeper dive at kind of what that is so that our audience kind of gets a better sense of TMB?

Dr. Ankur Parikh: Yeah. So we're still really understanding what TMB really is, but we know that some cancers express a high tumor mutational load or a burden load. So these cancers make these antigens that are probably potentially making the cancer grow and making it worse. But what we do know is patients that do have a higher tumor mutational burden load tend to respond to immunotherapy better. I think right now, the poster child really is lung cancer. We know a lot of patients, because of cigarette smoking, they may have a lot of inflammation, a lot of antigens in their body. So these patients may respond well to immunotherapy, potentially because of that type of tumor growth pattern. So we're still learning. It doesn't work for everybody. But that's sort of in a nutshell what tumor mutational burden or TMB is. But I think more to come in the coming years.

Dr. Pat Basu: That's very, very helpful, and I agree. I think the greater advancements that we can make there and try and predict who will be helped by certain immunotherapies and to what extent I think is absolutely an area that we're going to make a lot of progress on in the months and years ahead. Dr. Parikh, you mentioned earlier the way that immunotherapy drugs work, and you mentioned checkpoint inhibitors and cytokines. One of the things you mentioned was vaccines. I'm wondering if you could just expand a little bit on what you meant there in terms of vaccines in the context of immunotherapy.

Dr. Ankur Parikh: There's still a lot in the research setting. I think right now, there's definitely evidence of vaccines potentially helping prevent cancers, such as the HPV vaccine in relation to cervical cancer. We are starting to look for specific antibodies or antigens that might, once you have that exposure, cause these cancers to either grow or spread or potentially even develop. So they're still, I think, in the more research phase at this point, but eventually, there could be an opportunity to have these cancer vaccines as also an adjunct treatment to these cancers. There's other treatments out there with something called tumor infiltrating lymphocytes, where we're sort of trying to understand the biology of these tumors and generate a specific antigen response in the lab and then re- inject them in patients to get these hopefully good responses to their cancer. But that's still a lot of research in that area to happen.

Dr. Pat Basu: Thank you. Well, Dr. Parikh, I'd like to shift gears a little bit. This is the part of the show where we get to specific patient questions that have been submitted, and I think there's a lot that are relevant here. I'm going to pick a few. This is a patient that wants to know specifically why immunotherapy isn't more widely used against breast cancer. I know you mentioned that lung cancer was kind of becoming the poster child for immunotherapy, but to this patient, can you help sort of shed some light on the role of immunotherapy in breast cancer?

Dr. Ankur Parikh: Right, and it's a great question. I wish we had immunotherapy options for all of our patients, but kind of going back to a well- structured clinical trial and identifying which patient populations will respond better, and specifically to breast cancer, recently the FDA did approve immunotherapy in combination with chemotherapy with a specific subset group of patients with breast cancer called triple negative breast cancer. But outside of that, there's clinical trials that are ongoing, but unfortunately there's no evidence currently that immunotherapy has a role in advanced cancers that are not triple negative at this point. So I think the research is still happening, and hopefully we have those options in the future, but currently outside of a trial there's [inaudible 00:25:33].

Dr. Pat Basu: But as you were answering that question, I think it jogged something else I just wanted to make clear for our audience, is that immunotherapy doesn't necessarily need to be a mutually exclusive treatment. It can be given to patients who have been treated previously or in conjunction with other therapies. Anything you'd like to kind of expand on that?

Dr. Ankur Parikh: Yeah. So there's a lot of data now with combining chemotherapy with immunotherapy, and so sort of going back to the lung cancer example, there's a group of patients that actually do better with that combination of chemotherapy and immunotherapy. Even in that breast cancer population with the triple negative breast cancer, it's that combination therapy. So there is something to be said about the role of chemotherapy still and how that could potentially play a role with manipulating the immune system and potentially propagating or improving responses to immunotherapy. So we're still learning a lot about that, but I think combination therapies are really going to coming soon in the forefront and potentially even using it more in the early stage cancer setting as well.

Dr. Pat Basu: Yeah, I definitely, definitely agree. Sticking on that same theme of various cancer types, this is from a patient who writes," I have stage four ovarian cancer and was told I have no options left. Are there any new advancements in treatments coming against my disease?" Well, first of all, before I pass it over to you, I guess one thing I would say to this patient, as I know you and I have both seen many, many patients who have had advanced cancer, various types where they're told that they don't have any options left, and we've certainly seen evidence where that wasn't the case and patients that have successfully gone on to treat. But specifically to this patient's question on ovarian cancer, stage four, what you might advise.

Dr. Ankur Parikh: Yeah. So I would say talk to your doctor about potentially getting genomic testing done and checking for these biomarkers that might suggest immunotherapy working for you, because right now, you're right in the sense that immunotherapy doesn't have a standard role per se in advanced ovarian cancer outside of the clinical trial setting. But if your tumor does have some of these biomarkers or mutations, which would predict responses to immunotherapy, that's a whole different story. So I'd really advocate that you talk to your physician or oncologist about getting that testing done.

Dr. Pat Basu: Yeah, and that actually is... It ties pretty directly to a direct question from a patient that is wanting to know about biomarkers. Dr. Parikh, you talked about tumor mutational burden. You just talked about biomarkers in looking for candidates for disease. So this patient wants to specifically know why are biomarkers checked on some patients and not others?

Dr. Ankur Parikh: So I think everyone's learning, right? So genomic testing was not something that we learned about in medical school. It's sort of an evolving field, and lung cancer was really one of the first to adopt it. It's actually been incorporated into national guidelines now. So recently, there are certain genomic tests that have been approved through insurance and that can be offered for patients with advanced cancers. I just don't think all oncologists yet necessarily feel comfortable ordering it or maybe even have the ability to interpret the results or have resources for clinical trials to apply the potential treatment options. So I think it's a great question, and I think everyone is still learning, but it's sort of that whole education piece about looking for genomic testing options for your tumors. So talk really to your doctor about this and see, are there specific mutations you may harbor that no one knew about or didn't look for that might offer better treatment options for you? Not even necessarily immunotherapy, but other targeted treatment options.

Dr. Pat Basu: Yeah, that's great advice. I think we have time for one more question. So kind of tough to pick here, but this is actually one that came in from a patient earlier, actually earlier last week, and the patient asked," Why is there more research being conducted with clinical trials on certain cancer types versus others?" Can you kind of share how that process works?

Dr. Ankur Parikh: Yeah, and that's a tough question. Believe me, for a guy that sees a lot of GI cancers, it can often be frustrating as well. But a lot of it has to go with how common are these cancers? What's the funding behind it? Can you get a large group of people to enroll in these trials in a quick manner so you can really answer the question of whether a treatment is better than another or safer than another? So usually with breast cancer, colon cancer, lung cancer, a lot of the more common cancers, you'll see potentially more advances just because there's more people with those types of cancers. When you have rarer cancer types, like a gastric cancer or a neuroendocrine tumor, oftentimes, you don't get to see a lot of those big clinical trials with hundreds or even sometimes thousands of patients, just because you don't have that type of volume there to be able to get that many patients to enroll. So it's a very complicated question, and it can also be very frustrating, but I think, again, going back to the whole precision medicine and genomic testing and targeted therapies, a lot of times, there are clinical trials now that are agnostic to where the cancer actually originated from, but really more honed in on what the tumor profile looks like. So those could really be good options for patients that have some of these rarer types of cancers.

Dr. Pat Basu: Yeah. I agree. I think I would maybe just build with two of the points that you made, that when you and I are were training, we used to sometimes just talk about the cancers based on the organ of origin, breast cancer or ovarian cancer. But now there's so much more specificity around a specific mutation that I sometimes say that instead of ten cancers, there's 10,000 different types because of that aspect. The second is a point that you made which is, no question about it, there are more clinical trials in the more common cancer types, but to that patient and others, as a society and within oncology, I feel that we're getting much better at having small clinical trials for patients who may have a less common mutation or things like that. So I think that provides a lot of hope, and to those patients who maybe have a tumor that's not a part of the common types of cancer, there are plenty of resources out there that can help you get to a clinical trial, if there is one.

Dr. Ankur Parikh: No, absolutely. So I would just say always ask your doctor," Are there any clinical trials for me?" and especially with now with social media, I mean, you can really try to find patient advocacy groups. There's a lot of foundations out there even for these rarer types of cancers that you can get more insight or information from. So really explore all these options, because the world is so different than it was years ago. So Pat, as we talk more about immunotherapy and sort of the positive impact it has on patients, moving forward, we're really going to see a lot of this in more patients in different stages of their cancer journey, potentially from the beginning all the way to potentially when they have metastatic advanced disease, because we're already there at this point. But how do you see this potentially disrupting the healthcare system as we have it today? For example, a lot of these immunotherapy drugs have gotten approval to be offered every four weeks recently, FDA approval because of COVID. There's one immunotherapy drug that I can offer my patients every six weeks. So this is really different than what we were normally having our patients come to a clinic. So how do you see the future of immunotherapy as it impacts healthcare and cancer?

Dr. Pat Basu: Yeah, I think that's a terrific question, Dr. Parikh. From my perspective, I think about some of these disruptive advancements, these tremendous advancements as changing the entire landscape of healthcare, certainly in terms of just quality outcomes. I think this is a better... In patients who can tolerate and are candidates for immunotherapy, I think you're going to see better survival, better quality of life from a quality perspective. So incredibly excited about that. I think any time you move into a more targeted therapy, you think about 20, 25 years ago, we were doing big, open surgeries. We're now doing much more targeted surgeries, right? Immunotherapy I think will be a much more targeted, finessed approach, which will mean that we'll have less of the kind of larger therapies that we're going to not have to deploy to patients who are candidates for immunotherapy. Then, finally, it's impossible to talk about the healthcare landscape today without talking about cost and accessibility. So one of the things that is my personal mission is to not only have an American healthcare system that delivers excellent, best in the world quality of care, but also that's accessible and affordable. So as you mentioned there, I think immunotherapy offers incredible quality, the ability to get it for an extended period of time, and something I'd like to see is making sure it's affordable for patients and also for the healthcare system.

Dr. Ankur Parikh: Yeah, no, absolutely, because especially in those patients that are responding well to immunotherapy, I mean, I have patients that have been on immunotherapy for three years now, going on four, and I'm sure others have even longer. So it's just sort of what does that cost add to our healthcare system? But, obviously, your patient's doing incredibly well, with an amazing quality of life.

Dr. Pat Basu: Yeah. I love your example there. I think immunotherapy is a great pathway that can turn cancer into a chronic disease. If you think about the older paradigm, surgery or radiation early on and then maybe a patient enters some mode of what we might call survivorship, or I prefer the term that thrivership, hopefully meaning that they're thriving, but immunotherapy, as you mentioned before, can be something that the patient takes for years, and that's a wonderful advancement. But you're right. That can lead to the same issues that other chronic conditions have, and I think as a society and as physicians, what we need to make sure that we do is provide these advancements for patients, but also do so in a way that they can access it and afford it so that they're not having to choose between a life- saving therapy and paying for food or rent. So I know you and I have conversations about that, and it's something that we work on together. I love to end the show by asking wonderful guests and experts like you what advice or parting thoughts that you might have for our audience.

Dr. Ankur Parikh: Yeah. So I'm really big on education, and I think it's very important to understand what type of cancer you have, sort of what are your treatment options, and, really, what could be the next potential option, right? So a lot of times, patients will say," Well, I'm on this treatment. I don't know what the next plan is going to be." So really have an honest conversation with your doctor, because I think when you have that better relationship to really be on the same page with expectations and options, I think it works wonderfully, just because you're both advocating each other. Go and look for other options and opinions, too, and bring it back to your doctor, because I think there's just so much information now and so many different things that you really have to look at all of this, because there's so many things out there. So just open communication, trust, I think those are the big things out there right now. Really just keep your eyes out, because with these clinical trials and really the advances in oncology care, there's going to be so many new, different options that weren't even around last year.

Dr. Pat Basu: Yeah. It goes back to a point you said at the very beginning, which is that given that cancer changes so quickly and advances in science occur so rapidly, it's a tremendous aspect for advancements in cancer care, but it leads to a possibility that patients sometimes may not be aware of all of the various options. So the importance of asking around and doing that research is critical. So, well, Dr. Parikh, it's really been a pleasure having you. I know you're a very busy physician on the leading edge of precision medicine and immunotherapy. Really appreciate you taking some time out to join me and our audience on the show. So thank you for everything you're doing, and thanks for taking the time.

Dr. Ankur Parikh: Yeah. Thank you, Pat. This is a great opportunity, and I love that you're doing this and sharing all this helpful information to everybody, because I think it's just so valuable to get these honest opinions to really improve patient care and get more education. So thanks for doing this, and happy to be back.

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